Your Complete Guide to Rotator Cuff Injury

By Jonathan S. Chu, M.D.
Interventional Pain Management
Physical Medicine and Rehabilitation

You often hear about rotator cuff injuries in the media.

Every day, there are high-profile athletes around the world who are undergoing surgeries or physical therapy for their rotator cuff tears.

In fact, boxing great Manny Pacquiao was dealing with a rotator cuff injury during his famous bout with Floyd Mayweather. He later said in interviews that the injury may have cost him the match.

 

However, rotator cuff injuries don’t only affect world-class athletes.

 

Injury to the rotator cuff is one of the most common causes of shoulder pain in the world, and can affect people from all walks of life.

 

Sure, they can prevent major league baseball pitchers from throwing as effectively, or fighters like Manny Pacquiao from delivering jabs as fiercely.

 

But they also have a major effect on everyday people throughout the world.

An injury to the rotator cuff can make it much more difficult for a mother to care for her child. They can keep a worker from being able to operate his equipment. They can keep a father from throwing a football with his son.

 

It is a diagnosis I see very commonly in my practice, so I want to take some time to explain everything you should know about what the rotator cuff is, how it works, why it can hurt, and what you can do to feel better.

First, let’s talk about anatomy.

 

The rotator cuff refers to a group of four distinct muscles of the shoulder.

They serve to stabilize the joint and assist with movement.

They are often referred to as the SITS muscles. Each letter stands for one the 4 important muscles of the rotator cuff.

 

Supraspinatus

Infraspintatus

Teres Minor

Subscapularis

 

These four muscles surround the shoulder joint and capsule.

 

They are tremendously important for two reasons:

First, they serve to hold the humerus (long bone of the arm) in the shoulder socket.

Next, they are crucial for performing various movements of the arm.

The rotator cuff muscles allow you to rotate your arm inward and outward, and also allows you to bring your arm away from your body (abduction).

Why Does The Rotator Cuff Hurt?

 

You see, though these muscles are so important, each muscle is actually quite small and attaches to the humerus via a tendon. These small tendons are susceptible to injury.

 

The supraspinatus is especially vulnerable to injury because it passes directly below a bony structure of the shoulder known as the acromion.

 

Repetitive overhead activities (pitching baseballs, painting overhead) cause the supraspinatus and the other rotator cuff tendons to repeatedly rub against the acromion. This can eventually lead to microinjury, tears, and inflammation.

 

Some people are even born with an acromion that has a “hooked” shape, which puts them at higher risk of developing injuries to the rotator cuff.

 

The subacromial and subdeltoid bursa are fluid-filled sacs that sit between the rotator cuff and acromion, helping to reduce friction and allow smooth motion of the shoulder.

 

When painful injuries of the rotator cuff occur, these bursa can become very inflamed.

 

When physicians perform injections designed to relieve pain from rotator cuff injuries, they will most often target these bursa with their medication.

 

It is important to note that degeneration of the rotator cuff is not necessarily painful!

 

Lots of people in the general population develop small tears in the rotator cuff with aging and everyday activities, and do not experience pain or loss of the range of motion of their shoulder.

 

In fact, I would say that the majority of rotator cuff tears are inconsequential. There are countless people everywhere walking around with small tears, living their lives normally, and aren’t even aware that they have one.

 

However, pain is all about inflammation…and when the tears become inflamed and painful—then it is absolutely necessary to seek treatment.

 

A mild to moderate rotator cuff tear may not bother you for a decade—but then one particular day of intense yard work may cause a severe shoulder pain flare-up that could sideline you for weeks.

 

Since it is the inflammatory component of the pain that is the most critical, many physicians will refer to a shoulder pain flare-up as subacromial bursitis. This is directly referring to the intense inflammation in the fluid-filled sac that surrounds the rotator cuff.

Treatments for Rotator Cuff Tears

 

Non-Steroidal Anti-Inflammatory Medications (NSAIDs)

Anti-inflammatory medications are one of the most common treatments of rotator cuff injury. This includes medications such as naproxen (Aleve), meloxicam (Mobic), ibuprofen (Advil, Motrin), and diclofenac (Voltaren). Many of these are available over-the-counter.

 

Especially during the early and most intense period of the flare-up, these can be really useful to control the pain and allow you to start moving again.

 

These medications are not without side effects, however. If taken at higher doses and over longer periods of time, they can irritate the lining of the stomach, and also have adverse effects on the kidneys and heart. Thus, it’s definitely a good idea to talk with your physician about how to best use these medications.

Subacromial Bursa Injections

This is a procedure I do very often in my practice. It usually works really well to quickly extinguish a pain flare-up arising from the rotator cuff.

 

With this injection, you physician will draw up a mixture of a numbing medication and steroid medication. The steroid will act as a potent anti-inflammatory.

 

After cleaning the area, your physician will insert the needle into the subacromial bursa, either from the side or the back of the shoulder.

 

Once the needle is in the proper place, your physician will deliver the medication to the area, bathing the rotator cuff with the medicine.

 

Most often, your physician will use bony landmarks of the shoulder to locate the bursa and guide the injections.

Sometimes ultrasound will also be used to guide the needle with live visualization. This allows for an increase in accuracy, and also allows for confirmation that the medicine is spreading into the right place.

Physical Therapy

Once the pain flare has been brought under better control, physical therapy is the mainstay of treatment.

 

Physical therapy for a rotator cuff injury will emphasize a few goals:

 

First, you will want to learn exercises that stabilize your shoulder blade (scapula). This includes strengthening muscles such as the trapezius and the serratus anterior. This gives you a strong foundation to build upon with additional exercises.

 

Next, you’ll need to work on restoring the full range-of-motion of the shoulder. Restoring your ability to move is absolutely key from a functional standpoint. It’s also critical for preventing a serious condition known as frozen shoulder (adhesive capsulitis).

 

Lastly, it will also be important to learn exercises to strengthen the rotator cuff itself.

 

It’s important to keep in mind that the vast majority of patients with rotator cuff injuries will fully recover through physical therapy—sometimes along with a little help from medications and injections as well.

Dedicate yourself consistently to your therapy and home exercises, and over time, the odds are absolutely in your favor to make a great recovery.

Surgery

In some cases, the rotator cuff tear is not classified as mild or moderate.
In some cases, the tear is severe, and can involve the entire thickness of the rotator cuff.

 

With this scenario, your doctor may recommend surgical repair. Though the vast majority of rotator cuff injuries can be successfully treated with conservative treatment—the most severe injuries may require surgery.

 

That being said…a substantial portion of patients with even full-thickness tears do get better without surgery.

 

This is why there aren’t definitive guidelines regarding when to operate on the rotator cuff, and why it’s critical to consider the entire picture before moving forward with surgery.

The acuity of your injury, the degree of activity limitation, and the severity of your pain all need to be taken into consideration along with your MRI.

Surgery should also be a consideration if your shoulder pain is not improving even after 6 to 12 months of therapy, or if there is substantial weakness of the shoulder itself.

Thank you so much for reading. I absolutely commend you for taking the time and effort to educate yourself about your pain.
As a physician, I believe it is so crucial to take a proactive approach to your health. I know that your dedication will pay off over time.

Until Next Time,

Jonathan S. Chu, M.D.

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Dr. Jonathan S. Chu is a physician who specializes in Interventional Pain Management and Physical Medicine and Rehabilitation (PM&R), and is the founder of 360 Pain Academy.

Dr. Chu earned his medical degree from the Penn State College of Medicine / Milton S. Hershey Medical Center. Afterwards, he completed an internship in Internal Medicine at Lankenau Medical Center. Next, he pursued residency training in the field of PM&R at the Weill Cornell Medical Center and Columbia University Medical Center Combined Program. He went on to fulfill a fellowship in Interventional Pain Medicine at the University of California, San Diego Medical Center, where he learned advanced procedures for the treatment of pain from renowned leaders in the field.

He is double board certified in Physical Medicine and Rehabilitation and Pain Medicine.

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Edwards P, Ebert J, Joss B, Bhabra G, Ackland T, and Wang A. Exercise Rehabilitation in the Non-Operative Management of Rotator Cuff Tears: A Review of the Literature. International Journal of Sports Physical Therapy. 2016 Apr; 11(2): 279–301.

Marx RG, Koulouvaris P, Chu SK, and Levy BA. Indications for Surgery in Clinical Outcome Studies of Rotator Cuff Repair. Clinical Orthopedics and Related Research. 2009 Feb; 467(2): 450–456.

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